Therapy Intake Form (Adult)

Please correct the errors described below.

Emergency Assistance

If this is an emergency, call:

Crisis Line: (XXX) XXX-XXXX
911

Client Information

First name

Last name

Date of birth

Gender

Contact Information

Phone number

Email address

Address

Can we contact you by phone, email, and voicemail?

Yes No

If no, what is your preferred method of communication?

Personal History

Do you use drugs?

Regularly Occasionally No

Do you smoke?

Regularly Occasionally No

Do you drink alcohol?

Regularly Occasionally No

Do you drink caffeine?

Regularly Occasionally No

Do you gamble?

Regularly Occasionally No

How often do you get a full night of sleep?

Regularly Occasionally Never

Do you exercise?

Regularly Occasionally No

Do you have a healthy and balanced diet?

Regularly Occasionally No

How often do you have time for fun and recreational activities?

Regularly Occasionally Never

Is there anything else regarding your personal history that we should be aware of?

Reasons for Visit

Describe the reasons you are seeking therapy.

Describe any goals or outcomes you hope to achieve from therapy.

Describe any significant life changes or stressful events that you have recently experienced.

Is there anything else you'd like to tell us about?

Your information will be encrypted.

Emergency Assistance

If this is an emergency, call:

Crisis Line: (XXX) XXX-XXXX
911

Mandarin Counseling

904-260-0454
www.mandarincounseling.com
12058 San Jose Blvd #703, Jacksonville, FL, 32223, USA

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